1. hobbies and interests
2. games
3. gambling

Pathological Gambling Treatment Literature Review
(Second Edition)
Director:
Jim Emshoff, Ph.D.
Date:
December 2007
Researchers: Ayana Perkins, M.A.
Lindsey Zimmerman B.A.
Angela Mooss, MS
Jennifer Zorland, MS
For additional information, please contact:
Jim Emshoff at (404) 413-2029
Correspondence can be addressed to:
GSU Gambling Project
Attn: Jim Emshoff
Department of Psychology
Georgia State University,
140 Decatur St., 11th Floor
Atlanta, GA 30303
Acknowledgements
We would like to thank the Department of Human Resources, especially Bruce Hoopes and Neil Kaltenecker, for
their commitment to this issue and facilitation of this work.
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Georgia State University-2
TABLE OF CONTENTS
Executive Summary
4
Introduction
Legal Gambling in the United States
Prevalence of Gambling
Gambling and Treatment in the State of Georgia
5
Defining Pathological Gambling
Treatment Data
Types of Gambling Behavior
DSM-IV Diagnostic Criteria for Pathological Gambling
Phases of Pathological Gambling
8
Characteristics of Pathological Gamblers
Impulse Control
Biological Characteristics
Comorbidity
12
Consequences of Pathological Gambling
Family and Finances
Legal
Physical
15
Treatment Approaches
Behavioral Treatments
Cognitive Treatments
Cognitive Behavioral Treatments
Gambler’s Anonymous
Group Therapy
Pharmacotherapies
Minimal
Multimodal Treatments
16
Recommendations
39
Discussion
40
Conclusion
46
References
48
Appendix
65
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EXECUTIVE SUMMARY
This report presents a review of literature from 1964 to 2007 on the treatment of
pathological gambling. The report was created to assist with planning treatment interventions for
problem gamblers and to identify training needs for providers in the state of Georgia. The
treatment modalities covered in this literature review are as follows: 1) Behavioral; 2) Cognitive; 3)
Cognitive Behavioral Treatments; 4) Gambler’s Anonymous; 5) Group Therapy; 6)
Pharmacotherapies; 7) Minimal Interventions; and 8) Multimodal. Literature findings of each
treatment modality are examined to assess the most appropriate treatments for pathological
gambling.
Findings
•
The social consequences of gambling (i.e., criminal justice, therapy, court fees) (Walker,
2003), indirectly and directly costs American society $54 billion per year (Grinols, 2004).
•
Gaming revenue is the primary source of treatment funding in most states where gambling is
legal (State policymakers and providers struggle to fund and treat gambling addiction, 2005)
•
The gambling prevention research has implied a need for the improved training of treatment
personnel in screening and treating pathological gambling, need for more stringent controls
on underage gambling activities, more rigorous and empirically sound research, and creation
of new prevention modalities. (Emshoff, House, & Broomfield, 2000; Petry & Armentano,
1999)
•
Gambling treatment policies vary across states with many mental health and addiction
agencies serving as the governing agency (State, 2005).
•
Advocates for the needs of problem gamblers emphasize the importance of delivering
proper training for those who provide access to gambling treatment and those who deliver
the actual treatment (Gambling as a co-occurring disorder, 2005).
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INTRODUCTION
The purpose of this report is to update the 2000 literature review on treatment outcomes of
pathological gambling1 interventions from 1964-2000. These data were retrieved using journals,
books, the Internet, and online databases which include the following: Academic Search Premier, Alt
Health Watch, CINAHL, Health Source, Humanities International Index, MasterFile Premier, Medline,
Lexis/Nexis, PsycARTICLES, Psychology and Behavioral Sciences Collection, PsychINFO, Sociological
Collection, and PsycExtra. The data sources were identified using a combination of retrieval operators
when using electronic databases and online search engines. The creation of retrieval operators
resulted from the interchangeable usage of synonyms of words related to this topic (e.g. pathological
gambling, problem gambling, behavioral addiction, etc.).
The availability of information on gambling treatment outcomes is relatively small when
compared to other Diagnostic and Statistical Manual – Fourth Edition (DSM-IV) classified
disorders, which can likely be attributed to uncertainty about how to classify the disorder (Potenza,
2006). Pathological gambling is labeled as an impulse disorder (DSM-IV 2000), but most treatment
interventions are based on substance abuse models (Potenza, 2006). The degree to which
pathological gambling is behaviorally based or a result of physiological dysfunction also remains
unclear. Therefore, with the etiology and course of pathological gambling still not resolved by the
field, more research will be needed to determine the best treatment models. The studies in the
review to follow describe the best practices in the treatment of pathological gambling to date.
Recommendations to consider for future treatment programs are found at the end.
1
Pathological Gambling as defined by the Diagnostic and Statistical Manuel – Fourth Edition (DSM-IV) of the America
Psychiatric Association (2000).
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Legal Gambling in the United States
Legal gambling practices are used by various states to generate supplemental revenue (State,
2005). State-sanctioned gambling practices began with lotteries and scratch off games in the 1960's.
The trend continued into the 1980’s and has expanded into other gambling practices such as pulltabs, card rooms, casinos, riverboat casinos, video lotteries, and gambling on the Internet. In 1988,
with the advent of casinos on Native American reservations, the prevalence of gambling
skyrocketed, especially in Native American populations (Westermeyer et al, 2005). This spread of
legalized gambling brought the total spent on gambling in the U.S. to half a trillion dollars by 1998,
with $31.5 billion spent on annually on state lottery games (National Opinion Research Center,
1999). The increase of gambling practices in the United States has led to an increase in problems
associated with this activity (Freiberg, 1995; Grinols, 2004; Welte, 2001). This increase has been
associated with the proliferation of a gambling culture in the media and mainstream culture
(Castellani, 2000; Raylu & Oei, 2004). There is increased incidence of physiological, psychological,
and financial problems as gambling behavior becomes more severe (American Psychiatric
Association, 1994; Pasternak & Fleming, 1999, Petry, 2000). The evidence linking increased access to
legalized gambling to gambling problems (especially among the poor and minorities) (Volberg &
Boles, 1995; National Research Council, 1999; Welte, et. al., 2001) create the need to investigate the
efficacy of prevalent gambling treatment options.
Prevalence of Gambling
In 1999, Shaffer, Hall, and Vanderbilt reported that the prevalence of problem gambling
among adults had increased between the years 1974 and 1997. This comprehensive study analyzed
results from 119 pathological gambling prevalence studies conducted over the course of 20 years. In
the earlier (1977-1993) studies, 2.9% of the general population was classified as probable compulsive
gamblers and another 0.8% as pathological gamblers. The more recent (1994-1997) studies indicated
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that probable compulsive gambling and pathological gambling have increased to 4.9 % and 1.3 %,
respectively. Furthermore, they ascertained that this increase in pathological gambling prevalence
was most likely the result of the interaction between personality and social setting (1999).
Gambling and Treatment in the State of Georgia
In 1993, Georgia established its first legal lottery in over one hundred years. The gambling
products used to generate funds for the state are instant-win scratch off game cards, lottery tickets
(Cash 3, Cash 5, Fantasy 5, MegaMillions, Win for Life) and Keno (Georgia Lottery, 2007). Georgia
raised $1.13 billion, with $330 million of those monies going to fund educational programs such as a
college scholarship fund, a voluntary pre-kindergarten program, and other educational projects in its
first year of operation (Georgia Lottery, 1994; Volberg & Boles, 1995). It was mandated that the
Georgia Lottery Corporation should annually devote $200,000 of unclaimed winnings to programs
for the prevention and treatment of problem gamblers (1994).
Aside from the lotteries, there are also other gambling opportunities for Georgia gamblers.
Casino boats dock in Brunswick Georgia (Georgia Casinos, n.d.). In addition, Georgia is surrounded
by states where various forms of gambling are legal: South Carolina, Florida, and Alabama. Florida
has pari-mutuel gambling (horse racing, dog racing, jai alai), casinos (absent of table games such as
craps, blackjack, and roulette), and gambling cruise ships (Florida casino guide, 2007). Alabama
gambling activities are limited to Native American tribal land and offshore gambling (Alabama,
2007). South Carolina has video gambling, bingo, dog racing and offshore gambling (World Casino
Directory, 2007). Technological advances have made gambling easily accessible through the
Internet, which have limited safeguards to prevent adolescent gambling.
Prevalence of States Gambling Treatment Program
Gambling treatment is predominantly paid through the gaming industry with states using
different routes to receive and deliver treatment (States, 2005). There are few stand alone gambling
treatment departments with 28 states giving single authority for gambling prevention and treatment
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to their preexisting mental health and substance abuse departments (2005). Pathological gambling’s
has a high co-morbidity with general mental health disorders and substance abuse disorders (Welte,
Barnes, Wieczorek, Tidwell, & Parker, 2001) which may explain why so many state health
departments have placed gambling under a combined substance abuse and mental health state
agency. Other states have separated mental health and addiction agencies resulting in mixed
placement of gambling intervention services (2005). The absence of a stand alone gambling
department may complicate the search for treatment. Being housed in other departments like
mental health or substance abuse also may influence funding cuts or the type of funding sources
available for gambling treatment (2005).
DEFINING PATHOLOGICAL GAMBLING
Treatment Data
Within the last 5 years, there has been an increase in treatment data as more researchers are
finding evidence for efficacious gambling treatment models. The first version of this treatment
literature review cited 80 treatment studies completed between 1964 and 2000 (Courtenay-Quirk, C.
& Emshoff, 2000). The current document builds on evidence in the 2000 literature review and
identifies 65 new treatment outcome articles on pathological gambling completed in the last seven
years with the greatest increase found in pharmacological interventions.
Types of Gambling Behavior
Although studies sometimes use terms such as gambling, problem gambling, compulsive gambling,
and pathological gambling interchangeably, there are behavioral differences that distinguish one term
from another. Gambling is defined as: Any betting or wagering, for self or others, whether for
money or not, no matter how slight or insignificant, where the outcome is uncertain or depends
upon chance or skill (Gamblers Anonymous, 2000). Problem (probable compulsive) gambling is
defined as an involvement in risky gambling behaviors that adversely affect the individual's wellbeing. This may include issues related to relationships, family, financial standings, social matters and
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vocational pursuits (Arizona Council on Compulsive Gambling, Inc. 1999). Problem gambling is
not found in the DSM-IV but is considered a precursor to compulsive gambling if the behavior is
not reversed. Compulsive (pathological) gambling is defined as a progressive disorder
characterized by a continuous or periodic loss of control over gambling; a preoccupation with
gambling and with obtaining money with which to gamble; irrational thinking; and a continuation of
the behavior despite adverse consequences (Arizona Council on Compulsive Gambling, 1999).
DSM-IV Diagnostic Criteria for Pathological Gambling
The American Psychiatric Association recognized pathological gambling in 1980 in the
DSM-III as an impulse disorder. Persistent and recurrent maladaptive gambling is indicated by five
(or more) of the following:
•
Preoccupation with gambling
•
Gambling with larger amounts of money to increase excitement
•
Repeated efforts to reduce or stop gambling
•
Restlessness or irritability when attempting to control gambling behavior
•
Gambling to escape problems or to alleviate a negative mood
•
Trying to win back money after incurring losses while gambling
•
Lying about the extent of gambling behavior to significant other(s)
•
Committing crimes to finance gambling
•
Lost relationships with significant other(s) or lost career advancement because of
gambling
•
Dependent on others to provide financial assistance to relieve a debt caused by gambling
Two different types of gamblers emerge under the category of pathological gambling:
Action gamblers and Escape gamblers (Arizona Council on Compulsive Gambling, 1999). The
reasons for gambling, kinds of gambling activities, and chances for recovery differ between the two
types of gamblers.
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Action gamblers are more likely to have domineering personalities and above average IQ’s.
Although they exude energetic and assertive behavior, they generally suffer from low self-esteem.
Action gamblers tend to start early in life (adolescence) and prefer games of skill such as poker or
dice games (1999). Action gamblers believe they can develop a system to “beat the house.” This
type of gambling is more prevalent among men (1999).
Chances for long-term recovery for action gamblers are low, although they are more likely to
improve if they receive professional help by a trained specialist. Those who participate in a recovery
program often follow it up with a 12-Step program for themselves as well as their spouses.
On the other hand, escape gamblers are more likely to be nurturing and responsible
individuals. They prefer games of luck such as bingo and slot machines. They tend to begin their
gambling activity later in life and use gambling for escape or empowerment. Escape gamblers are
more often women. Escape gamblers are more likely to seek professional help than action gamblers,
and stand a better chance of achieving long-term recovery (Arizona Council on Compulsive
Gambling, 1999).
Phases of Pathological Gambling
Pathological gambling often progresses through a series of phases (Arizona Council on
Compulsive Gambling, 1999). The winning phase (three to five years) is characterized by
pathological gamblers winning more often than they lose and some may have experienced some big
wins. Sometimes they attribute their winning to being smarter than others, which justifies spending
more time and money gambling. However, this winning phase doesn't usually last and eventually
pathological gamblers move into the losing phase. The losing phase may last more than five years.
As gamblers lose more than they win, they place larger bets in an attempt to "chase losses". They
may begin to lie or borrow money to cover losses as they sink deeper into financial trouble.
Eventually resources for bailouts dwindle, and their personal lives rapidly deteriorate as they
progress towards the desperation phase. The desperation phase can vary in length, as most of the
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gambler's time at this point is spent preoccupied with some aspect of gambling. Signs that one is in
the desperation phase may include a significantly problematic family life and career or engaging in
illegal activity such as embezzling. They may suffer from depression and experience suicidal
thoughts. Although outwardly gamblers in the desperation phase may still appear in control, most
have lost all control over their gambling. Some may be willing to accept help during this phase. A
possible fourth phase has also been proposed - hopeless/giving up phase (Rosenthal, 1989). In
this phase, pathological gamblers know they can't recoup losses and do not care anymore. This
feeling of hopeless also compels them to continue to gamble (Rosenthal, 1989).
CHARACTERISTICS OF PATHOLOGICAL GAMBLERS
Demographics
The pathological gambling research provides insight into the personality of a problem
gambler. The current research of pathological gambling has defined several characteristics of
problem gamblers (See Table 1.). Problem and probable pathological gamblers in Georgia are
significantly more likely to be young, and non-white than non-problem gamblers in the general
population, and they are significantly less likely to be married and to have graduated from high
school than non-problem gamblers (Volberg & Boles, 1995). Problem & pathological gamblers start
gambling at a significantly younger age than non-problem gamblers (Volberg, 1995). A 1998 study
found a 4% to 7 % prevalence rate of problem gamblers between the ages of 11 and 18 (Proimos,
DuRant, Pierce, & Goodman, 1998). Although limited research has been done on the gambling
practices of women, the New Jersey gambler's hotline reported that 24% of the callers were women
(Council on Compulsive Gambling, 1999).
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Characteristics of Compulsive Gamblers
Who Is
Compulsively
Gambling?
•
•
•
•
Young (earlier behavior = higher prevalence)
Non- White Men
Unmarried
Uneducated
Attributes
•
•
•
•
•
•
•
•
•
Impulsivity
Hyperactivity
Distractibility
Attention Deficit Disorder
Genetic Predisposition
Higher levels of Norepinephrine
Financial: Bankruptcy; Eviction; Repossession; Job Loss
Legal: Credit Card Fraud; Loan Fraud; Theft; Embezzlement
Physical: Headaches; High Blood Pressure; Cardiac Problems;
Asthma; Intestinal Disorders; Anxiety Attacks
•
•
•
•
•
•
•
Depression
Suicide
Drug/Alcohol Abuse
Tobacco Use
Compulsive Shopping
Compulsive Sexual Behavior
Personality Disorders: Anxiety, Intermittent Explosive, Antisocial
Biological
Characteristics
Consequences
Comorbidity
Impulse Control
Pathological gamblers often expressed aggressiveness and low anxiety in childhood (Vitaro,
Arseneault & Tremblay, 1999) and were more likely to have experienced attention deficit disorder,
hyperactivity and impulsivity (Taber, Russo, Adkins, & McCormick, 1986). Pathological gamblers
have been found to be highly distractible and have poor impulse control (Lacey & Evens, 1986;
Carlton & Goldstein, 1987; Carlton & Manowitz, 1987; Carlton & Manowitz, 1992; Rugle &
Melamed, 1993; Castellani & Rugle, 1995). Achievement through sustained effort and delayed
gratification is viewed as less interesting than immediate gratification and success to compulsive
gamblers (Taber, Russo, Adkins, & McCormick., 1986). High impulsivity has been identified as a
potential risk factor for problem gambling among adolescents (Vitaro, Arseneault & Tremblay,
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1999). Attributes of pathological gambling can be viewed as manifestations of impulsive behaviors.
This impulsivity has four basic elements:
1.
Excessive sensitivity to potential reward and desire for immediate reinforcement
2.
Tendency to respond impetuously without forethought of negative consequences
3.
Excessive sensitivity to threatened punishment (non-reward)
4.
Deficits in inhibitory control that keep the person responding despite the risk of negative
consequences (Buss & Plomin, 1975; Eysenck & Eysenck, 1977; Barratt & Patton, 1983;
Carlton & Manowitz, 1987; Gray, Owen, Davis, & Tsaltas, 1983; White, Moffitt, Caspi,
Bartusch, Needles, & Stouthamer-Lofber, 1994).
Although most studies point to impulsivity as an attribute of gambling, some studies have shown
that gambling behavior might be due to partial reinforcement of past gambling behavior, which
would render the behavior very resistant to extinction (Carlton & Goldstein, 1987; Carlton &
Manowitz, 1992; Rugle & Melamed, 1993).
Biological Characteristics
Some studies have found biological characteristics related to compulsive gambling. Miller's
study in 1997 found elevated levels of norepinephrine in pathological gamblers. They describe a
"rush" often experienced during a period of anticipation for a winning result or in preparation for
gambling (Miller, Gold, & Smith, 1997). Additionally, Eisen and Lin (1998) studied monozygotic
and dizygotic twin pairs and found a possible familial vulnerability (genetic or experientially based) in
pathological gamblers.
Comorbidity
There is evidence that the comorbidity rate with other psychological disorders amongst
problem gamblers may be as high as 90%. Steffgen (1995) found a strong link in characteristics
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between compulsive gamblers and people with attention-deficit disorder (ADD). She discovered
that between 30% and 43% (depending on the criteria) of gamblers met the diagnosis for ADD.
Among the most common disorders that accompany problem gambling is depression. Studies show
that on a lifetime basis, the depression rate in pathological gamblers is between 70 and 76 %
(McCormick, Armstrong, Blaszcynski & Allcock, 1984). Not surprisingly, the suicide rate amongst
compulsive gamblers is also quite high. A study of Gamblers Anonymous members found that 12 18 % have attempted suicide, 45-49 % have made plans to kill themselves, 48-70 % have
contemplated suicide, and 80 % reported that they "wanted to die" (Thompson, Gazel, & Rickman,
1999). Studies have found that some of the highest suicide rates are in Las Vegas and Atlantic City
(Becona, Del Carmen, & Fuentes, 1996) and Reno (Cohen, 1998).
Black and Moyer (1999) found evidence that 47% of compulsive gamblers recruited during a
public campaign in Iowa were drug or alcohol abusers. For the participants in Stinchfield and
Winter’s 1996 study, the majority of gamblers (69%) used tobacco on a daily basis. Studies also
found that 43% of compulsive gamblers engaged in other compulsive behaviors such as shopping
(23%), sexual behavior (17%), and intermittent explosive disorder (13%) (Black & Moyer, 1999).
Many compulsive gamblers experience a range of psychiatric illnesses. Eighty-seven percent
met the criteria for personality disorder (Black & Moyer, 1999). Other psychiatric disorders include
mood disorders (60%), anxiety disorders (40%), substance abuse disorders (63%), and antisocial
personality disorder (33%) (Black & Moyer, 1999).
CONSEQUENCES OF PATHOLOGICAL GAMBLING
The problems associated with pathological gambling reach far beyond the psychological
consequences. Gamblers also experience personal, financial, legal and physical crises as a result of
their gambling behavior.
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Family and Finances
Often pathological gamblers get caught in a cycle of debt, which can affect their financial
stability and employment (Unwin, Davis, & De Leeuw, 2000). Stinchfield and Winters (1999) found
that the majority of their sample (94%) experienced at least one gambling-related financial problem
in their lifetime, with debt sometimes reaching hundreds of thousands of dollars. Lesieur (1998)
found that bills are often overdue and in extreme cases this challenge can lead to eviction,
repossession of household items or automobiles, and even foreclosure on their homes. The burden
placed on families of the disordered gamblers is high with divorce as one out of many unfortunate
consequences (Volberg & Boles, 1995). Often, the pathological gambler's behavior affects their
work as well. Ladouceur and Walker (1996) found that 69% to 76% of gamblers admit to having
missed work due to gambling.
Legal
Stress related to personal and financial burdens can lead to anxiety, depression and cognitive
disorders. This stressful experience can cause impaired judgment for pathological gamblers and lead
them into criminal activity in an attempt to recover their losses (Blaszcynski, McConaghy, &
Frankova, 1991). A strong association was found between gambling frequency and criminal
behavior, suggesting that some criminal activity may be related to financing gambling (Brown,
Killian, & Evans, 2005). Sixty-three percent of Gamblers Anonymous members reported writing
bad checks; 30.1% reported stealing from the workplace; and 50.6% claimed they stole to finance
gambling or to pay off gambling debts (Schwer, Thompson, & Nakamuro, 2003). A meta-analysis
of 27 articles (published between 1990 and 2004), examined the prevalence of gambling in forensic
populations. This analysis revealed that one-third of criminal offenders are problem or pathological
gamblers, the highest prevalence found in any population (Williams, Royston & Hagen, 2005).
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Physical
Financial burdens, family problems, and illegal activities often lead to stress related physical
problems for the pathological gambler. This population has been found to display a wide array of
physical stress illnesses including chronic or severe headaches, intestinal disorders, asthma,
depression, anxiety attacks, cardiac problems, and high blood pressure (Lorenz & Yaffee, 1986).
TREATMENT APPROACHES
The first treatment center to offer services for pathological gamblers was implemented in
Ohio in 1968. As of 2007 there were fewer than 205 clinicians that were nationally certified
gambling counselors. (National Council on Problem Gambling, 2007). The majority of treatment
modalities use counseling as a mechanism for treatment. Pharmacology is the only treatment that
does not directly require counseling, but in practice it is normally provided with a treatment modality
that involves counseling (Korn & Shaffer, 2005).
Behavioral Treatments2
Behaviorists believe that gambling is a learned behavior, initiated and maintained by positive
and negative reinforcement of arousal, winnings, or both. As mentioned earlier, gamblers describe a
“rush” associated with gambling. This arousal effect is an internal reinforcement of the gambling
behavior. Some behaviorists attribute pathological gambling to a repeated seeking out of this
arousal state (Anderson & Brown, 1984). Other behaviorists attribute pathological gambling to the
positive reinforcement of winning and its random reinforcement schedules (Anderson & Brown,
1984). This intermittent reinforcement tends to sustain behavior because the odds of winning are
random and it keeps the person guessing about when and whether a payoff will happen (Sarafino,
1996). Still, other behaviorists, such as McConaghy (1988), believe that once a behavior becomes
habitual, a behavior completion mechanism is established in the gambler’s nervous system. If the
behavior is not carried out when the person is stimulated to do so, they experience a tension so
2
The present literature review identified no new intervention studies between 2000 and 2007 that used solely a behavioral intervention
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aversive that they are compelled to perform the behavior. This experience is similar to symptoms
experienced by people with obsessive-compulsive disorder. Four major categories of behavioral
treatment include aversion therapy, imaginal desensitization, imaginal relaxation, and in-vivo
exposure.
Aversion therapy was the major focus of early research on pathological gambling (Lester,
1980). Electric shock and chemical aversion (inducing vomit) are the most common forms of
aversion therapy, with electric shock therapy being preferred because it is cheaper, safer, and less
humiliating to the client. During aversion therapy, a therapist administers shocks as the patient
performs or views the undesirable gambling behavior. Some examples include using gambling
apparatuses such as one-armed bandits (Barker & Miller, 1966) or watching slides of gambling
stimuli (poker hands or roulette wheels) (Seager, 1970).
The behavioral therapeutic strategy has been found to be effective in short term cessation of
gambling behaviors, but not with long term behavior changes (Barker & Miller, 1968; Lesieur, 1998;
Koller, 1972). Koller (1972) reported that at the end of treatment eight of the twelve patients he
treated had stopped gambling, but at follow-up only three remained abstinent. In two case studies,
aversion therapy was paired with other behavioral therapies, specifically contingency management
and controlled gambling (Dickerson & Weeks, 1979; Rankin, 1982). In these cases, the goal was not
abstinence, but reduced gambling, which was achieved by both participants. Reduced gambling was
operationalized as one weekly gambling session wagering a small amount of money and establishing
a weekly gambling limit. The positive results of these case studies emphasize a need for more
investigation into long term outcomes of this treatment strategy.
Imaginal desensitization teaches patients techniques on how to gradually relax using mental
concentration. Patients are then asked to imagine scenarios in which they have gambled before, but
instead of experiencing gambling induced stress, they leave the situation remaining relaxed. Patients
begin visualizing the least anxiety-provoking scene, increasing in intensity as the patients master the
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relaxation techniques. McConaghy, Armstrong, Blaszcynski, and Allcock (1983) found imaginal
desensitization more effective in reducing gambling behaviors, gambling urges, and anxiety than
aversion therapy in a comparative study of twenty participants. Imaginal relaxation is very similar to
imaginal desensitization. Both treatments involve teaching the client relaxation techniques, but in
imaginal relaxation, clients are asked to visualize relaxing images, whereas imaginal desensitization
focuses on the anxiety provoking situations, such as gambling. When comparing the effectiveness
of imaginal desensitization versus that of imaginal relaxation, McConaghy, Armstrong, Blaszcynski,
and Allcock, (1988) found no differences (10 participants) in outcomes after treatment and at oneyear follow-up.
In-vivo exposure treatment also involves relaxation techniques. Once the client has learned
the relaxation methods, they are exposed to an actual gambling situation for different specified time
periods (usually increasing with time). In Blaszczynski, McConaghy, and Frankova (1991) treated
120 clients with one of four techniques: imaginal desensitization, imaginal relaxation, aversion
therapy or in vivo exposure. Of the 63 participants retained in the study, 18 reported abstinence, 25
reported controlled gambling and 20 reported continued uncontrolled gambling. The authors
reported no significant differences in effectiveness based on treatment received. Those who
reported controlled gambling and abstinence showed comparable improvements in social and
financial functioning and decreased ratings of psychopathology compared to those who reported
uncontrolled gambling. Some pathological gamblers have taken treatment into their own hands and
have requested to be banned from casinos in Missouri (Savoye, 2000). Korn and Shaffer (2004)
identified this conscious avoidance as a type of self imposed behavioral intervention. The state
blocks casinos from sending any marketing material to those who elect to self-ban and enforces the
ban by arresting these individuals and charging them with trespassing if found in casino. In
addition, casinos request identification to enter the premises and will turn away anyone who has
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been banned. As of yet, there have not been any published formal evaluations of the impact of this
type of treatment approach.
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Behavioral Treatment Summary
Behavioral treatment is considered one of the stronger modalities within the field (Korn &
Shaeffer, 2004). Support for this type of treatment stems from the fact that there have been more
outcome studies that utilized random assignment of client groups, and tracked outcomes at six
months and 12 months after treatment was completed. Many behavioral approaches have seen
success in substance abuse treatment, which enhanced its credibility for treating other addictive type
disorders. One major detractor of behavioral treatment modality is the low frequency of behavioral
treatment studies within the last ten years, despite many changes in gaming activities, gaming
policies, and with populations at risk during this time period. This trend may be related to the more
recent emphasis on multimodal gambling treatment style, with a dominant emphasis of merging
cognitive structuring techniques with behavioral modification strategies.
Cognitive Treatments
According to cognitive theorists, the fundamental mistake made by gamblers is an erroneous
perception of the notion of randomness (Ladouceur & Walker, 1996, Gaboury & Ladouceur, 1989).
Gamblers believe that they can control their winnings or that gambling outcomes are predictable.
They develop mistaken beliefs that losing increases the odds of future winnings or that winning
predicts future winnings. Cognitive dissonance, an incongruence of personal belief and fact, results
since the odds of winning at gambling are random and therefore independent. Problem gamblers
begin to develop strategies that they believe will increase their chances of winning. According to this
perspective, even when the gambler initially does not expect to win, he or she develops a set of
beliefs that encourage continued gambling. These false beliefs, in which a person feels they can
control events governed by chance, maintain high gambling activity (Sylvan, Ladouceur, & Boisvert,
1997). These incorrect notions lead gamblers to have biased evaluations of gambling results and
falsely believe that over time their outcomes will even out (Fizel, 1997). The goal of cognitive and
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cognitive-behavioral treatments is to challenge these beliefs in order to modify the gambler’s
behavior.
Toneatto and Sobell (1990) reported a case study in which they challenged the participant’s
belief system regarding personal control of outcomes, future winnings balancing current losses, and
financial losses due to gambling being trivial. The client’s self-reported gambling was reduced from
seven times a month before treatment to once a month at post-test, and once every two months at
6-month follow-up. In 1998, Ladouceur, Sylvain, Letarte, Giroux, and Jacques treated 5
pathological gamblers with cognitive restructuring, which resulted in increased realistic perceptions
of the control of outcomes in gambling. Four of the 5 participants maintained “therapeutic gains”
but the authors did not specify whether these gains referred to abstinence or controlled gambling.
A 2003 case study described a middle aged man diagnosed with pathological gambling and
clinical depression, who received cognitive modification to reduce his disordered gambling, as
abstinence was not his treatment goal (Boutin, Dumont, Ladouceur, & Montecalvo, 2003). After 14
sessions over a six month period the participant no longer met DSM-IV criteria for pathological
gambling. However, the authors noted that he had developed a substance abuse problem.
“Switching addictions” is common with substance and behavioral dependencies (Wanigaratne,
Wallace, Pullen, Keaney, & Farmer; 1991) with clients also switching from substance abuse to
gambling. In 1994 study, a 44 year old woman shifted from polysubstance abuse to pathological
gambling and then back to substance abuse (Blume, 1994)
Ladouceur, et al. (2001) coordinated several studies on cognitive only treatment. In this
study, the treatment group (n = 35) received cognitive correction and relapse prevention. The
outcome measures included DSM-IV criteria, self efficacy perception, and perception of control,
desire to gamble, South Oaks Gambling Screen (SOGS) scores, and frequency of gambling. There
were significant differences in outcome measures between the treatment group and the wait list
control group (n = 29). Nineteen members of the treatment group experienced better performance
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on at least four of the measures versus two of the wait list control group. A greater percentage of
those in the treatment group sustained the positive effects of the intervention at the 6- and 12month follow up. Cognitive restructuring is explored again in the Group Therapy section.
Cognitive Treatment Summary
Most of these studies have had low sample sizes and lacked efficacy data although other
studies have suggested the use of cognitive restructuring treatment for pathological gambling (Petry
& Armentano, 1999). Similar to behavioral treatment, there are few examples of cognitive only
treatment studies within the last ten years. The basic principles of this modality still have widespread
use when combined with other effective treatment approaches as seen in the following section.
Cognitive-Behavioral Treatments
Consistent with cognitive treatments, cognitive-behavioral treatments draw on the theory
that gamblers have incorrect beliefs about control of gambling outcomes. A common cognitivebehavioral treatment protocol consists of four components: (1) cognitive restructuring, (2) problem
solving training, (3) social skills training, and (4) relapse prevention (Bujold & Ladouceur, 1991;
Bujold, Ladouceur, Sylvan, & Boisvert, 1994; Sylvan, Ladouceur, & Boisvert, 1997). The goals of
cognitive restructuring are to challenge the belief system developed by the gambler and to correct
gambling misconceptions. A connection between poor-problem solving skills and gambling
behavior is discussed in problem-solving training. The patients are next taught a problem-solving
strategy. Patients later incorporate this strategy into coping with specific problems that lead to their
gambling. Node link mapping is one such problem solving activity in cognitive behavioral approach.
Node-link mapping is used to illustrate the path of cognitions, emotions, and behaviors during
therapy sessions and to improve understanding between the client and clinician (Melville C, Davis C,
Matzenbacher D, Clayborne J, 2004). This treatment was considered for pathological gambling
populations due to its successful use among chemically dependent groups. Node link mapping
treatment involves three approaches: Understanding randomness, problem solving, and relapse
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prevention (2004). Node mapping provides the client with a visual depiction of how thoughts,
actions, and external influences are linked and influence their addiction
Social skills training is similar to problem-solving training, in that patients discuss an
association between gambling behaviors and social skills during the training session. If a deficit is
identified in the client’s social skills, a specific training is prescribed. For example, if a client
reported that their gambling resulted from encouragement from their social network, they were
given assertiveness training (Sylvain, Ladouceur, & Boisvert, 1997) to counteract the social
influences.
The final component of this treatment is relapse prevention. Relapse prevention involves
discussing with clients the high-risk situations and reasons for returning to gambling behavior.
Once the facilitators for relapse are identified, the clinician and client develop a script of how to
more competently resolve vulnerable instances where the potential for relapse is high. Relapse
prevention has been tested in two gambling treatment studies (Bujold, Ladouceur, Sylvan, &
Boisvert, 1994; Sylvan, Ladouceur, & Boisvert, 1997) and found effective in the elimination and
reduction of gambling behaviors, respectively. Bujold and colleagues (1994) reported the abstinence
of their three participants from post-test through six month follow-up. However, these results may
not be generalizable to all problem gamblers due to the small sample size. Sylvan, Ladouceur, and
Boisvert (1997) reported reductions in gambling behavior and an increase in perceived control in
comparison to control participants. However, these results must be interpreted cautiously, as they
may have been influenced by the participant attrition rate of 36%. Of the 14 clients treated, only 9
were assessed at the 12 month follow-up. In addition, the authors did not differentiate between
controlled gambling and abstinence.
Freidenberg, Blanchard, Wulfert, and Malta (2002) assessed the effectiveness of motivational
enhancement therapy (MET) followed by additional cognitive behavioral intervention sessions
among nine participants who completed treatment. MET is its own therapeutic style that is
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designed to strengthen client’s motivation by addressing resistance and ambivalence (Mason, 2005;
Miller & Rollnick, 1991; Roffman and Stephens, 2006).3 Participants in the 2002 study received
three stage treatments: 1) one to three sessions of MET, 2) 10-15 sessions of cognitive behavioral
treatment, and 3) pathological gambling relapse prevention in the remaining two sessions. Pre- and
post-test measures included the South Oaks Gambling Screen and physiological arousal, as
measured by the 4Critikon Dinamap monitor. Participants showed significant decreases in both
measures post-test, lending support for the effectiveness of cognitive behavioral treatment.
Echeburua and Fernandez-Montalvo (2002) co-authored a case study on a middle age
housewife who suffered from pathological gambling. She received treatment in 9 sessions with 5 of
the sessions focused on behavioral treatment (stimulus control and gradual in vivo exposure with
response prevention), and 4 sessions in cognitive treatment (relapse prevention). The participant’s
daughter served as her co-counselor, providing support away from the psychologist’s office5. The
authors asserted the importance of tailoring the relapse prevention to adapt to the realities of the
patient. The client did not exhibit pathological gambling behavior at end of treatment or at the 12
month follow up.
Milton, Crino, Hunt, and Prosser (2006) examined compliance improvement with cognitive
behavioral treatment. Compliance improvement of gambling treatment involved the use of praise
and reinforcement of self efficacy. Forty subjects diagnosed as pathological gamblers were randomly
assigned to cognitive behavioral treatment or cognitive behavioral treatment with compliance
improvement. Lower symptoms of pathological gambling behavior were measured by the SOGS.
The individuals who received compliance improvement had significantly higher rates of completion
3
MET studies is not formally a subset of cognitive behavioral therapy. Many programs combine the use of MET and CBT and have met great
success (Mason, 2005; Roffman and Stephens, 2006). They are often used together for brief therapies with MET used in the readiness stage and
CBT for the action state (Roffman and Stephens, 2006).
4
This physiological measurement tool records heart rate and blood pressure.
5
Although this study is placed under cognitive behavior, this particular study would also be appropriate for a multimodal category through the
use of the daughter as counseling support. Family systems approach was highly recommended by GA Strategic Plan Stakeholders (Emshoff et
al., 2007).
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of treatment, lower amounts of money spent on gambling, and lower symptoms of pathological
gambling.
Another study by Hodgins, Currie, el-Guebaly, and Peden (2004) compared the use of brief
motivational enhancement therapy with a workbook against a workbook only treatment. The MET
was delivered over the phone in one 30 minute session. Equal groups of men and women were
randomly assigned to both treatment groups (the control group received treatment at a later date).
After 24 months, both the treatment and control group demonstrated a reduction in gambling
behavior, with greater success observed among the MET group. The Hodgins et al. (2004) study
provides support for the efficacy of short term cognitive behavioral treatment of pathological
gambling.
Cognitive Behavioral Treatment Summary
The cognitive behavioral approach has received strong support from leading gambling
treatment researchers and its efficacy is evidenced by its frequency in the literature (Korn &
Shaeffer, 2004; Ladouceur, 1994; Mason, 2005; Petry et.al, 2006; Sampl, 2006; Sharpe, 2002; Sylvain,
Ladouceur, and Boisvert, 1997; Toneatto & Ladouceur, 1990; and Toneatto & Ladouceur, 2003).
This approach has integrated two therapeutic strategies (cognitive and behavioral) that have
individually had success in gambling and other impulse and addictive disorders. Cognitivebehavioral’s high rating compared to other modalities is also based on the use of randomized clinical
trials; greater rates of abstinence at long term follow up (six month, 12 months, 18 months, and 24
months). This therapy can easily be delivered in brief sessions and strengthened through the use of
innovative strategies such as motivational enhancement therapies.
Gambler’s Anonymous
The first group meeting of Gambler’s Anonymous (GA) was held on September 13, 1957 in
Los Angeles, California. This autonomous self help organization does not accept outside donations
(Gamblers Anonymous, 2007) and has an affinity group for relatives of pathological gamblers,
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GamAnon (Moody, 2007). The group is led by a senior member of GA named the chairmen who
invites other GA members and visitors to share their stories of disordered gambling (Gambler’s
Anonymous-UK, 2007). Since its inception, GA has since become the most common treatment
approach for those seeking help for their gambling addiction (National Resource Council, 1999). It
should also be mentioned that some believe GA is not a treatment, but more of a supportive
fellowship (Korn & Shaffer). For the purposes of this literature review it is included as a treatment
because there are population groups who choose to go to GA instead of traditional treatment
settings to obtain help with their gambling problems.
GA is a 12-step program based on the model of Alcoholics Anonymous self-help program.
Consequently, GA encourages its members to achieve abstinence. GA provides incentives for its
members, such as social recognition of members who remain abstinent and reach program
milestones. There is controversy regarding applying the medical disease model of addiction to
pathological gambling behavior, as this model assumes that if a relapse occurs it will match in
severity to the most debilitating phase of the addiction cycle (Blaszczynski & McConaghy, 1989).
Blaszczynski, McConaghy, and Frankova,1991 found that not every lapse will lead to full relapse,
and that at least a sub-sample of pathological gamblers are able to tolerate re-exposure to gambling
behavior without long term loss of control. Furthermore, Marlatt and Gordon’s (1985) relapseprevention model argued that, depending on cognitive and/or affective responses, an initial lapse in
behavior was not always associated with a return to pre-treatment addictive levels of indulgence.
This finding is at odds with the central belief of GA that addiction is a lifelong disease that should
be treated with abstinence to stop the inevitable return to more debilitating symptoms and
experiences associated with pathological gambling (Gamblers Anonymous, 2007).
Several studies report that GA has a limited affect on achieving and maintaining abstinence
(Petry, 2003a; Stewart & Brown, 1988). Petry & Armento (1999) reported evidence that GA is not
effective. Specifically, 70 to 90 percent of GA attendees drop out, less than 10 percent become
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active members, and only 8 percent of the attendees achieve a year or more of abstinence (1999).
Similarly, Brown (1985) found that, of 232 attendees of GA meetings in Scotland, only 7.5%
maintained abstinence after 1 year of attendance, and 7.3% remained abstinent after 2 years. This
finding does indicate, however, that those helped by this approach may achieve long-term success.
It should be noted that these studies did not measure the severity of the gambling behavior
or the individual's perception of gambling addiction. More investigation is needed to assess if the
former GA members, who did not abstain from gambling, relapsed into maladaptive gambling
behavior or were able to moderately gamble.
Several studies found that when GA is used in conjunction with other forms of treatment, it
can be an effective tool for maintaining abstinence after the initial treatment phase is finished
(Russo, Taber, McCormick, & Ramirez, 1984; Petry, 2003). Taber et. al. (1987), found that 74% of
patients who were abstinent had attended at least 3 GA meetings, compared to 42% of those who
were not abstinent. Active participation in GA may encourage the use of social support to maintain
abstinence (Brown, 1985).
One study suggested that individuals who attend GA may have different needs than those
who do not (Petry 2002). Among 321 participants, those who participated in GA had more severe
gambling problems and poorer relationships with family members. However, they were able to
sustain abstinence longer (2 months), and were more engaged in treatment. Participants without a
history of participating in GA were more likely to actively abuse substances and were less engaged in
treatment.
GA Treatment Summary
There is a dearth of empirical evidence that offers support of GA as a singular long term
effective gambling treatment. GA’s is used a supplemental resource to other treatment types (Petry,
2003a). Many treatment settings require attendance at GA to help compliment other treatment
approaches, and is often recommended as a resource to prevent relapse (Korn & Shaffer, 2004).
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These groups are not required to be facilitated by a licensed clinician. Some participants have
reported negative experiences within GA meetings (Taber & Chaplin, 2005) related to comments
made by other group members. The national support of Gambler’s Anonymous and its availability
in many different venues make this treatment an attractive option. However, limited findings on its
long term singular success in the treatment of pathological gambling may indicate that until more
data is found to support its sole use, it should be used only as a supplement to other more
efficacious therapies.
Group Therapy
The genesis of group therapy can be found in the lack of therapists available to deliver
individual therapy during World War II (Corey & Corey, 1997). Formal group therapy is not
attached to one psychotherapeutic tradition or disorder (1997). The managed interaction between
group members can serve in cathartic function through allowing the group exchange to advance
therapeutic gains (Taber and Chaplin, 2005). Past studies have reported that group treatment for
pathological gambling is preferable to individual treatment when participants were exposed to both
treatment formats (Lesieur & Blume, 1991; Saiz-Ruiz, Moreno & Lopez-Ibor, 1992).
Due to success with a cognitive-only, individualized intervention (Ladouceur et al, 2001),
Ladouceur and colleagues duplicated the study using a group therapy approach (Ladouceur et al.,
2003). Participants were randomly assigned to a treatment group or to a wait list control group. The
group cognitive treatment study had lower rates of attrition, which the researcher attributed to the
dynamics of group treatment. Positive outcomes were detected at 6 months, 12 months, and 24
months.
Pathological gambling group therapy has been enhanced through node-link mapping. In the
2004 study, researchers conducted two experiments using node mapping in group treatment. In the
first experiment (2004), 13 participants were randomly assigned to the node mapping group (n=4), a
non mapping group (n=4), and a wait list control group (n=5). All three groups demonstrated
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significant improvement in self-reported ratings of gambling control, reduction in gambling
expenditures, duration, abstention, and DSM IV ratings of pathological gambling. These treatment
gains remained significant at a six month follow-up. There were only nine participants in the
second experiments that were randomly assigned to node mapping group or wait list control group.
The dependent variables for the second group included anxiety, depression, and DSM IV criteria.
Decreases in anxiety, depression, and DSM IV symptomology of pathological gambling found in the
second experiment (2004).
Group Therapy Summary
Data are minimal for the group therapeutic strategy in pathological gambling (Dowling,
Smith, and Thomas, 2007). Among the few treatment studies that do exist, only one directly
compares individual and group using the same treatment, duration, and theoretical approach (2007).
Results of other group treatment comparison studies indicate therapeutic gains are experienced in
group treatment (Blaszczynski, Maccalum & Jaukhador, 2001; 2007; Echeburua, Baez, & FernandezMontalvo, 1996. However, individual treatment in these comparison studies has resulted in
improved outcomes with longer lasting effects (2001; 2007; 1996)
A group approach may assist with reducing costs in therapeutic interventions (Dowling,
Smith, and Thomas, 2007; Teasdale, Walsh, Lancasher, & Matthews, 2003) and can be beneficial in
short term treatments ( Corey & Corey, 1997). The exchange between group members can assist
with achieving growth in the therapeutic process (1997; Taber and Chaplin, 2005). This technique is
widely used but seldom as a singular modality. Consumers are typically receiving some form of
individual counseling in addition to their group therapy (Ladouceur, Sylvain, Boutin, Lachance,
Doucet, & Leblond, 2003). The therapeutic style utilized is determined by the clinician leading the
group and the type of group (1997). Similar to GA, group therapy can be used as the sole
mechanism of receipt of gambling treatment. Although very practical and useful, the group therapy
may not be able replace benefits of the one-on-one attention in individual counseling.
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Pharmacotherapies
Since the 2000 literature review, twenty-three new studies were identified that used
pharmacotherapy for treatment of gambling. Many treatment centers use a multimodal approach
rather the exclusive use of pharmaceutical treatment for pathological gambling. The selection of
different types of pharmaceutical treatments is related to how pathological gambling is defined by a
researcher, based on the presentation of specific symptomology, or co-morbid disorders. If a
patient is experiencing a co-occurring disorder, choosing a pharmaceutical treatment considered
relatively efficacious for both disorders must be prescribed. When pathological gambling is
perceived as a type of addiction, pharmacotherapies such as naltrexone are recommended due to its
successful use in the treatment of alcoholism (Dannon, Lowengrub, Gonopolski, Musin & Kotler,
2005; Grant & Grosz, 2004; Grant & Kim, 2001; Kim, Grant, Yoon, Williams, & Remmel, 2006;
Kim, Grant, Adson, Shin, & Zeninelli, 2002; Kim, Grant, Adson, & Shin, 2001; Kim et al., 2001). If
defined as an impulse disorder, substances such as citalopram (used for the treatment of disorders
such as obsessive compulsive disorder) are recommended. There is also evidence of serotonin
dysfunction in pathological gamblers (Hollander, Frenkel, Decaria, Trungold, & Stein, 1992).
Opiod Antagonists
Opioid antagonists such as naltrexone and nalmafene have predominantly been used in the
treatment of alcohol and opioid dependence. More recently, their use has been extended to other
addiction and impulse disorders, such as pathological gambling. Naltrexone is more widely used and
has been cited in seven studies with pathological gambling patients (Dannon, Lowengrub,
Gonopolski, Musin & Kotler, 2005; Grant & Grosz, 2004; Grant & Kim, 2001; Kim, Grant, Yoon,
Williams, & Remmel, 2006; Kim Grant, Adson, Shin, & Zeninelli, 2002; Kim, Grant, Adson, & Shin,
2001; Kim et al., 2001).
In Kim’s (1998) study, three out of 15 patients suffering from impulse control disorder were
treated with naltrexone for nine months. One of the three patients was a pathological gambler who
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indicated experiencing a reduced urge to gamble. Another study assessed the impact of naltrexone
on 83 participants (Kim et al., 2001). Greater reductions were seen in the treatment group than the
control group. However, there was also larger attrition in the treatment group than the control
group. Kim, Grant, Adson, & Shin (2001) used the same study design but with 45 participants (20
received naltrexone and 25 received placebo). Naltrexone patients demonstrated greater
improvement with their impulse disorders(75%). Nausea was listed as a common side effect during
the first week of this study.
Similar results were found in a Kim & Grant (2001) study with 17 pathological gambling
participants. For six weeks, participants received open and flexible dosage of naltrexone. The
majority of participants began to notice a response to naltrexone through the reduction of
pathologic gambling symptoms by the fourth week of treatment.
Kim, Grant, Yoon, Williams & Remmel (2006), examined the potential dangers of liver
damage from long-term use (N=386) of naltrexone. Study results indicated that naltrexone use can
lead to elevated levels of hepatic enzymes, which can be reduced after one week if patients limit their
use of aspirin, acetaminophen, or non aspirin non steroidal anti-inflammatory drugs. Nefazodone
also an antidepressant that has been used for the treatment of pathological gambling, but the drug
was taken off the market by Bristol Squibb Meyers in 2003 after it was determined that it caused
liver damage. Clinicians who use pharmacological interventions must be aware of the long term side
effects of their use.
Anti-Depressants
Buproprion is a commonly prescribed antidepressant. Buproprion was compared with
naltrexone in a 12 week study by Dannon et al. (2005). Thirty six patients were recruited.
Seventeen participants were randomly assigned to buproprion and 19 to naltrexone. Twelve of the
buproprion group completed their 12 weeks with nine of the subjects abstaining from gambling for
two weeks and receiving higher scores on the Clinical Global Impression Improvement Scale.
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Thirteen of the completers for naltrexone treatment were able to abstain from gambling and earn
higher scores on the scale. The Dannon et al. (2005) results demonstrated that buproprion was as
effective as naltrexone for the reduction of problem gambling behaviors.
In another study, ten pathological gamblers with no comorbidities entered an 8 week open
label study of buproprion where both researchers and participants are aware of the pharmacological
treatment(Black, 1999). Results indicated participant improvement on scales of obsessive
compulsive behavior, attention deficit disorder, and pathological gambling (Black, 1999). Grant and
Grosz (2004) co-authored a study using a sample of adults over 60 years old, which provided much
needed data on this under-studied gambling population. Participants were given naltrexone,
antidepressants (citalopram, fluoxetine, fluvoxamine) or a combination of both naltrexone and
antidepressants. Eight of the participants (67%) across all treatments experienced a sustained
reduction in gambling symptoms for over one year.
Hollander and colleagues (1998) used fluvoxamine in a single-blind study to measure its
effectiveness in reducing or terminating gambling behavior. Of the 16 participants who were
recruited, 10 completed the study. Researchers found that seven of the ten who completed the
study achieved gambling abstinence. Again, no follow-up data were reported
Dannon et al. (2005) compared the effects of fluvoxamine against topiramate. Topiramate is
an anticonvulsant that is sometimes used for patients with mood disorders that are difficult to treat.
In Dannon’s study, there were 31 participants with 15 randomly assigned to topiramate and 16 to
fluvoxamine. Twelve people completed the topiramate treatment and 8 completed fluvoxamine,
75% of both groups indicated that their gambling behavior was in full remission.
A more recent treatment medication is 1-(meta-chlorophenyl) piperazine or m-CPP, which
has similarities with the anti-depressant, trazadone, and has been used in MDMA (ecstasy research)
and for treating of migraines (Pallanti, Bernardi, DeCaria & Hollander, 2006). Unauthorized
possession of this drug is illegal as it produces similar effects to MDMA (“ecstasy”). For this reason,
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this drug is not mentioned here as a likely treatment modality, but response to this drug was
measured by prolactin and cortisol levels, pathological gambling rating, mood, craving, and scales
that measured sensory elevation (“high”). Pathological gambling participants reported greater
sensory responses after treatment, which suggested to the researchers that more severe gamblers
may have a cerebral dysfunction at the 5-HT (Pallanti, Bernardi, DeCaria & Hollander, 2006).
Selective Serotonin Reuptake Inhibitors
Escitalopram is a selective serotonin reuptake inhibitor (SSRI) often used for generalized
anxiety disorder and depression (Grant & Potenza, 2006). In an open-label study including 12
patients administered an increasing dosage of escitalopram (the mean end study dosage was 25.4 mg
a day), the majority of the patients were responders (61.5%) (Grant & Potenza, 2006). Responders
were identified as those patients whose scores on the pathological gambling adaptation of the Yale
Brown Obsessive Compulsive Scale (PG-YBOCS) decreased by 30% at the end of treatment.
Responders also endorsed higher scores on other quality of life scores after treatment (e.g. The
Sheenan Disability Scale, Perceive Stress Scale, and Quality of Life Inventory).
Paroxetine is another SSRI used for anxiety. Two studies were conducted with different
results on how effective it is at treating problem gambling behaviors. In a 2002 Kim et al. study, 45
DSM-IV diagnosed pathological gamblers entered an eight week double-blind study. The treatment
group had higher post scores than the control group on the Gambling Symptom Assessment Scale
and the Clinical Global Impressions Scale. However, in the Grant el al. (2003) double-blind
paroxetine trial, no significant differences in gambling behavior between the placebo group (n = 40)
and the treatment group (n = 36) were observed.
Citalopram is also in the class of SSRI’s. In the Zimmerman, Breen, & Posternak (2002) trial
of 15 pathological gambling subjects, improvements were demonstrated for the treatment group.
Nine of the 15 completed the open label trial with improvements on all indicators of treatment
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response (Yale Brown Obsessive Compulsive Scale, Obsessive Compulsive Drinking Scale-Modified
for Problem Gambling, days and money lost to gambling, Clinical Global Impressions Scale).
Sertraline, another SSRI, was tested in two trials. In a 2004 case study, Meroni, Lo Giudice,
Kotzalidis , and Biondi reported reductions in pathological gambling behaviors after receiving
sertraline. In 2005 Saiz-Ruiz, Blanco, Ibanez, Masramon, and Gomez coordinated a pilot study of
the effects of sertraline on pathological gambling behavior. Sixty patients were enrolled in this
double blind, random assignment trial. Investigators did not find a significant difference in the
response of participants in the treatment (n=23) and placebo (n=21) groups on their outcome
measures (Saiz-Ruiz et al., 2005).
SSRI’s are used to treat the impulsivity evident in the manic phase of those with bipolar
(Gorman, 1997). They are both used as mood stabilizers, useful in preventing both mania and
depressive episodes. The use of these drugs in the treatment of gambling disorders seems
appropriate, since impulsivity is related to both pathological gambling (Lacey & Evens, 1986;
Carlton & Goldstein, 1987; Carlton & Manowitz, 1987; Carlton & Manowitz, 1992; Rugle &
Melamed, 1993; Castellani & Rugle, 1995) and bipolar disorder (Petry & Armentano, 1999) and
depression (McCormick, Russo, & Ramirez, 1984) are comorbid with pathological gambling.
Mood Stabilizers and Drug Interactions
Haller and Hinterhuber (1994) used carbamazepine, a mood stabilizer, to treat pathological
gambling in a male patient. This patient had previously tried other interventions such as behavior
therapy and self-help groups and had failed to abstain from gambling for more than three months
(1994). After treatment, the client reported abstinence for 30 months (1994). In a similar study
(Markowitz, 1980), they used lithium, another mood stabilizer, frequently used with bipolar disorder.
Three gamblers with bipolar disorder and was found to reduce impulsivity, subsequently reducing
gambling behaviors (1980). However, the magnitude of the reduction was not reported.
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More recently, Hollander et al. (2005) examined the use of sustained-release lithium
carbonate among 40 pathological gamblers with bi-polar disorder in a 10-week randomized
experimental study. Ten (83%) of the 12 participants in the treatment group were identified as
responders as compared to 5 patients assigned to the placebo group. In addition, improvement in
gambling severity was significantly correlated with improvement in mania ratings (Hollander et al.,
2005).
Treatment for Parkinson disease has caused some patients to develop pathological gambling
symptoms(Avanzi, Uber, Bonfa, 2004;Driver-Dunckley,Samanta,& Stacy, 2003; Montastruc,
Schmitt, Bagheri, 2003; Seedat, Kesler, Niehaus, and Stein,2000) In some cases, reducing the drug
treatment will eliminate pathological gambling symptoms (Dodd, Klos, Bower, Geda, Josephs,
Ahlskog, 2005). Quetiapine, an anti-psychotic, has been shown to be effective in pathological
gambling symptoms in a case study of a 41 year old male Parkinson patient(Sevincok, Akoglu, and
Akyol,2007).High dosages were administered to patient over a ten week period resulting in the
elimination of pathological gambling behavior (2007). Quetiapine is typically used for schizophrenia
but other off label use in addition to pathological gambling in Parkinson patients include posttraumatic stress disorder, restless legs syndrome, autism, and alcoholism.
Pharmacological Summary
These reports suggest that pharmacological treatment of pathological gambling may be
useful, but the validity of results are limited by extremely small sample sizes, high attrition rates, and
minimal follow-up data. Furthermore, researchers’ definitions of positive responses to treatment
vary, limiting comparisons across studies. There is no agreement as to which drug is most effective
in treating gambling behavior since medication is often linked to the co-morbid symptom of the
client. The side effects of these drugs are not always included in the studies, nor are their effects on
attrition commonly examined. Given the high rates of comorbidity between depression and
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pathological gambling, further investigation of anti-depressants’ effects on gambling behavior is also
needed (Petry & Armentano, 1999).
Minimal Interventions
The rising cost of healthcare is causing more patients to seek affordable alternative forms of
treatment, such as self-help literature. This form of intervention requires fewer resources and does
not necessarily involve the traditional role of a therapist to facilitate the progress of the client or
group. Minimal interventions range from ‘motivational interviewing’ to self-help manuals.
Motivational interviewing is an in-depth single session with a professional therapist, who
facilitates patient recognition of their problems, and strategizing and planning their own treatment.
Miller and Rollnick (1991) present evidence that a motivational interviewing approach may maximize
the benefit of a brief intervention and help engage people with addictive behaviors in therapy by
overcoming ambivalence and clarifying goals, thus increasing opportunity for positive change.
Dickerson and Weeks (1979) found that the use of a self-help manual significantly reduced gambling
alone or in conjunction with a single in-depth motivation interview.
Hodgins, Currie, and el-Guebaly (2001, 2004) examined minimal treatments for pathological
gambling participants that described outcomes at the end of treatment and at 24 month follow up.
Gains were found for the majority of clients who received motivational interviewing or a workbook.
Greater improvements were found for participants who received motivational interviewing at the
end of treatment and at follow up intervals (2004). The waitlist control group also demonstrated
improvement which may have been related to the anticipation of treatment (2004).
Minimalist Summary
The minimalist approach has favorable outcomes in changing gambling behavior, although
research is needed to replicate the described findings in this section (Dickerson and Weeks,1979;
Hodgins, Currie, and el-Guebaly, 2001; 2004; Miller and Rollnick, 1991). This treatment approach is
very cost effective to the consumer and for those who are providing the service. Considering the
Pathological Gambling Treatment Literature Review-Second Edition
Georgia State University-36
cost of health care and the possibility the individual might lack insurance coverage, this approach
could be a valuable first step in treatment of pathological gambling. If the gambler does not respond
favorably to this treatment approach, the treatment professional should offer the client a more
intensive intervention.
Multimodal Treatments
Many different aspects of a gambler’s life must be addressed if they choose to receive
treatment at an in-patient facility. Pathological gambling can result in serious consequences, such as
legal, financial, employment, health, psychological, and psychosocial problems. Since gamblers suffer
from several difficult issues, treatment centers often use a multimodal approach to specifically
address the complex problems stemming from gambling addiction. In-patient treatment programs
usually last 20-30 days and consist of a combination of medical valuations, classes on addiction,
relaxation therapy, assertiveness training, group psychotherapy, marital therapy, Gambler’s
Anonymous meetings and physical exercise (Griffeths & MacDonald, 1999).
The Gamblers Treatment of St. Vincent’s North Richmond Community Health Center
found significantly less gambling at termination of treatment (Blackman, Simone & Thoms, 1989).
At initiation, 79% of the sample (70 clients) were gambling daily and at termination only 6%
reported that they were gambling daily. (1989). Russo and her colleagues (1984) conducted a oneyear follow up study of 60 former inpatients who received treatment at the Brecksville Unit of the
Cleveland Veterans Administration Medical Center. Fifty-five percent of the respondents reported
complete abstinence from gambling after discharge from the treatment facility (Russo, Taber,
McCormick & Ramirez 1984).
Most pathological gamblers are not likely to receive services from clinicians experienced with
gambling-related problems (Petry & Armentano, 1999). Furthermore, these treatment centers
typically treat problem gamblers with programs that are geared towards patients with substance
abuse and/or depression, usually leaving the members and the co-facilitators of Gambler’s
Pathological Gambling Treatment Literature Review-Second Edition
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Anonymous to address the pathology of the gambler’s addiction. Additional investigation on
gambling specific treatment could provide data on treatment efficacy.
Kuentzel et al. (2003) was able to demonstrate the effects of a minimal intervention
(motivational interviewing) combined with pharmacotherapy. A 49 year old clerk received a 12 week
treatment regimen with 10 weeks of 20 mg fluoxetine (two week placebo) and four weeks of
motivational interviewing. Gambling symptoms were reduced after the end of the treatment and the
three month follow up.
A study (Petry et al., 2006) compared different combinations of treatment: Referral to
Gamblers Anonymous (GA), GA Referral plus a cognitive behavioral workbook, and a GA referral
in combination with 8 sessions of cognitive behavioral treatment. Greater improvement was seen
with participants with treatment sessions. However, participants who maintained abstinence in the
study either attended GA sessions, completed workbook assignments, or attended counseling
sessions with therapist. This study indicates potential efficacy of cognitive behavioral treatment and
GA.
Multimodal Summary
Pathological gambling behavior is often expressed in conjunction with anxiety, impulsivity,
depression, and substance abuse, which requires a comprehensive approach to eliminating or
reducing pathological behavior. Korn and Shaffer (2004) suggest that pathological gambling
behavior is more a syndrome since it most often presents with symptoms from other disorder
categories, e.g., substance abuse, depression, and anxiety. Multimodal appears to be the preferred
treatment method for some state programs (Stinchfield, 2001; Moore & Marotta, 2004). Oregon,
which has stabilized the incidence of pathological gambling within the last decade, has adopted a
multimodal approach that considers psychosocial and cultural needs of each client (Moore &
Marotta, 2004). The multimodal approach may help reduce the limitations of a singular therapeutic
strategy.
Pathological Gambling Treatment Literature Review-Second Edition
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General Summary
The study of pathological gambling is in its beginning phase, and more data is needed on its
treatment modalities. Studies of the effectiveness of treating gambling addiction typically have
relatively small homogenous sample sizes. The treatment approaches were rarely compared to
control groups. In those cases, researchers would assign half of the participants to a waiting list and
the remaining participants received treatment. However, the researchers could not present empirical
evidence to validate their results because many of the participants dropped out of the control group.
Lack of attrition in the intervention studies is common in treatment groups as well.
RECOMMENDATIONS
In 1999 The National Gambling Impact Study Commission (NGISC) conducted a study on
gambling in the United States. They issued a report based on their findings containing
recommendations that addressed many aspects of gambling.
The NGISC suggested that the regulation of gambling would best be handled on a state level
(except for tribal and Internet gambling). States should impose strict guidelines regarding campaign
contributions from those who have applied for the operation of gambling facilities. Because of the
difficulties in regulating and enforcing any proposed guidelines, Internet gambling was
recommended to be prohibited altogether.
Regarding pathological gambling, the NGISC suggested that states should also be
responsible for training casino staff and management in recognizing signs of problem gambling.
Service should be refused to customers who exhibit problem gambling behavior, and/or written
information should be provided (confidentially) on state-approved treatment programs or self-help
groups.
The commission also found that gambling facilities need to be involved in addressing
problem gambling. For instance, warnings about the risks and odds of gambling should be
Pathological Gambling Treatment Literature Review-Second Edition
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prominently posted, and policies prohibiting underage gambling should be strictly enforced.
Additionally, credit card cash advance machines should be banned from the premises.
Finally, the commission suggests that problem gambling needs to be approached from a broad
viewpoint. In addition to states and gambling facilities taking action, it is recommended that health
plans provide for the treatment of problem gambling and that Congress should encourage continued
research on problem and pathological gambling. Although not all of these recommendations are
applicable to the State of Georgia, they are all valuable to consider. Strict enforcement of underage
gambling, health plans that provide for treatment of problem gambling and continued research on
problem and pathological gambling are the most salient. To date, the United States has experienced
an increase in pathological gambling that has been linked to the increased access of legal gambling.
Durand Jacobs, PhD (Frieberg, 1995) has said that pathological gambling is the fastest growing
addiction among youth and adults. In order to prevent it from reaching epidemic proportions
(especially in Georgia) it is necessary to develop not only sound treatments, but also preventative
measures.
INSTRUMENTS
Researchers have been able to use different measures to identify gambling functioning. The
most frequently mentioned instrument among all of the studies is the South Oaks Gambling Screen
(SOGS). The majority of gambling instruments found in the reviewed treatment studies are
adaptations of instruments for addictive or impulse disorders. A list of the reported instruments can
be found in the Appendix.
DISCUSSION
The research to date on the problem of pathological gambling provides hope for those who
continue to struggle with problem gambling. Gambling is a relatively new field of research so more
data are needed to assess the long term outcomes of these treatment modalities. Most of the
treatment studies are plagued with the problem of high attrition rates, low sample sizes, selection
Pathological Gambling Treatment Literature Review-Second Edition
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bias, lack of control/ comparison groups, and homogenous samples. It is often difficult to
determine if other variables are influencing outcomes without access to data on incentives,
involvement in other types of treatment (e.g. 12 steps), and reasons why people drop out of studies
(Najavits, 2003). Alternative treatment approaches like meditation has been used in substance abuse
treatment (Plasse, 2001; Pruett, Nishimora, and Priest, 2007), yet, alternative treatment research for
gambling is lacking. Most disconcerting is the lack of focus on women, minorities, and people in
lower socioeconomic groups, which comprise a significant proportion of pathological gamblers
(Paternal, A. & Fleming, M., 1999; Volberg & Boles, 1995; Lesieur & Blume, 1991; Raylu & Oei,
2002), but historically have the least access to resources. In order to make this treatment findings
generalizable, research must be done on samples that are more representative (Daughters, et al.,
2003). Gamblers are a difficult population to study, as are most addiction populations , but in order
to make sound recommendations of effective treatments, research in this area needs to be more
rigorous and empirically sound (2003).
Many of the reviewed studies mention abstinence as a goal of treatment alongside controlled
gambling. In the review of treatments such as cognitive and cognitive-behavioral, researchers
measured treatment efficacy by operationalization of reduced controlled gambling. Research also
indicates that both abstinent gamblers and controlled gamblers show significant reductions in
indicators of pathological behaviors such as state and trait anxiety, neuroticism, psychoticism and
depression (Blaszczynski, McConaghy, & Frankova, 1991). Blaszczynski et al. (1991) indicated that it
its possible that controlled gamblers are more psychologically adjusted and can maintain control
over their behavior, whereas abstinent gamblers lack sufficient control over their behavior. The
standards for operationalization of controlled or reduced gambling as a viable outcome of treatment
should be developed and studied against the option of abstinence.
As noted earlier in document, pathological gambling often evidences itself with several other
disorders common in inpatient psychological institutions, such as depression, anxiety disorder, and
Pathological Gambling Treatment Literature Review-Second Edition
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substance abuse. Implicit in these findings is a call for the standardized use of a gambling instrument
to ensure that assessment is uniform and individuals suffering from problem or pathological
gambling can receive assistance. Given these high comorbidity rates, intake personnel should be
adequately trained to assess and treat pathological gambling. It has been documented that additional
training is specifically needed in Georgia (Emshoff, House, & Broomfield, 2000). Training should
include information on cognitive behavioral treatments, comprehensive multimodal treatments
(motivational interviewing and MET), and treatments that should be used in supplemental fashion
such as GA, group therapy, and pharmacological interventions. Minimal interventions should be
presented as a way to tailor treatment of populations who have higher attrition rates or an
intervention for those groups who are at risk for problem gambling, e.g., college students. This
training also should involve the identification of factors that could affect treatment outcomes. A
brief description of factors that influence gambling treatment outcomes can be found below.
Treatment Failures
Treatment outcomes are worthy of study due to the potential benefits for both clients and
treatment staff (Shaffer, LaBrie, LaPlante, Kidman, and Donato, 2005). Treatment failures are
especially noteworthy because they could indicate that a therapeutic strategy is harmful or provide
data on the appropriate use of a particular treatment. Learning about treatment failures is as
important as learning about treatment success (Tonneato, 2002). These data can assist therapeutic
staff become more effective in their work. Data are also needed on if treatment failures differ across
special population groups as found among people with a history of gambling treatment who
frequently experience higher treatment failure (Daughters, Lejuez, , Lesieur, Strong & Zvolensky,
2003).
Gambling Treatment History
Another factor to be considered is whether the presenting client has a history of treatment.
Gamblers with a longer history of pathological gambling experience more treatment failure
Pathological Gambling Treatment Literature Review-Second Edition
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(Daughters, Lejuez, , Lesieur, Strong & Zvolensky, 2003). History of earlier treatment is often
collected at intake but the extent that these data are utilized remains unclear. The use of these data
could decrease recidivism and attrition rates at treatment facilities.
Type of Gambler
A thorough assessment of the origin and factors contributing to pathological gambling is
critical before treatment begins (George & Murali, 2005). Factors that influence a type of
pathological gambling should necessitate a particular type of treatment. Pharmacotherapy agents
should be applied based on the type of gambler and any comorbidities. Impulse pathological
gamblers may benefit from a short term combination of CB and pharmacotherapy. Escape
pathological gamblers may require CB treatment for other psychological disorders (e.g. depression
or anxiety) and could further tackle this emotional avoidance by also including GA in their treatment
regimen.
Gender differences also seen within pathological gamblers. Higher rates exist for
pathological gambling among men ( Volberg, 1996). Walker, Cournega,& Deng, 2007) attribute this
difference to males being more driven by the behavior of influential males or tendency to socialized
to be adventurous. Women are more likely to have other comorbid conditions such as problem
drinking. Women are also more likely to use an outpatient program rather than residential treatment
(Westphal, 2003). This preference for outpatient programs may be related to their role as primary
caregivers.
Efficacy of Treatment Approaches
The most common treatment interventions aimed at pathological gamblers are 1)
Behavioral Treatments; 2) Cognitive; 3) Cognitive Behavioral Treatments; 4) Gambler’s Anonymous;
5) Group Therapy, 6) Pharmacotherapies; 7) Minimal Interventions; and 9) Multimodal treatments.
In addition, efficacy is rated on a scale of 1 to 5, with 1 being ‘Poor’ and 5 being ‘Excellent’ (Table
2). It should be noted that no treatment modality received a rating of ‘Excellent’.
Pathological Gambling Treatment Literature Review-Second Edition
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Table 2: Efficacy of Treatment Approaches
Treatment Approaches
Ratings*
Scale: 1 - 5
Limitations
Behavioral
3
Found effective in shortterm cessation, no longterm efficacy shown.
Cognitive-Behavioral
4
More data needed on those
who withdrew from the
study.
Multimodal
4
Few long term studies
conducted, lack of control
groups
Gambler’s Anonymous
3
Small samples, lack of
control group, self-reported
outcomes
Cognitive
3
Minimal Interventions
3
No operational definition
of abstinence, lack of
control groups, small
samples. No long term
efficacy shown
Small sample, no control
group, no operational
definition of abstinence
Pharmacotherapies
2
Small samples, no long
term evidence available.
More data needed on the
type of gambler (action or
escape) and presenting comorbid conditions.
Improvements/
Implications of Research
Implications for combination of
treatments and outcome of
controlled gambling (reduced
gambling) **
Controlled gambling as a viable
outcome as well as abstinence.
Relapse prevention component
has positive implications and can
be considered in other treatment
modalities. Minimal exposure of
these treatments shows promise
**
Controlled gambling as a viable
outcome as well as abstinence.
Popular form of treatment in
public institutions. Need for more
longitudinal research **
Seen as a viable treatment in
conjunction with other types of
treatment
Only abstinence defined as
effective **
Controlled gambling seen as a
viable outcome as well abstinence
Need for larger samples and
longitudinal studies**
Viewed as a possible cost
effective treatment. Appears
promising with newer studies.
More research needed with larger
samples and use of control group
**
Controlled gambling seen as a
viable outcome, more research
needed with larger samples. **
The report’s rating table indicates that there is no ideal treatment. By understanding the
limitations of each of these therapeutic styles, practitioners may be able to increase treatment
successes. Additionally, knowledge about the factors that influence treatment outcomes may
Pathological Gambling Treatment Literature Review-Second Edition
Georgia State University-44
influence therapeutic staff to design programs or contingency management measures that may
reduce the potential for relapse and increase probability of completing treatment. Milton (2006)
suggests borrowing from other behavioral addiction treatment models. Using reinforcement models
such as parking spaces, water bottles, or other clinic privileges may inspire unresolved gamblers to
complete and maintain abstinence or control their gambling. Many of the treatment approaches
could considerably improve abstention or reduction in pathological gambling behavior if combined
with other efficacious therapies. Referrals to self help groups like GA should also include a linkage
into a long term abstinent GA member (Petry, 2002). The use of family systems or community
support may prevent the escalation of depressive symptoms as seen in Echeburua and FernandezMontalvo’s 2002 study.
These findings also have implications for the training of general medical
personnel, such as physicians, and physicians’ assistants to recognize health implications stemming
from pathological gambling. This can even be expanded to include counselors in public health
centers, school counselors and mental health paraprofessionals in both inpatient and private
practices.
In states where gambling is legal, there should be strict controls set up to limit adolescent
access to gambling practices. Studies have shown that the age of onset of gambling behavior is
significantly lower for pathological gamblers than for those who are non-problem gamblers
(Volberg, 1995). This implies that the earlier a person begins gambling, the more likely they are to
become pathological gamblers. A study of young Americans and Canadians found that between
Five to eight percent of Americans and Canadians under eighteen have a serious gambling problem
compared to 1-3 % of adults (Willenz, 1998). Furthermore, adolescents are also least likely to
determine that they engage in problem gambling (Ladouceur, 2004). The alarming prevalence of
problem gambling among adolescents and its implications on future pathology and costs to
government warrant tighter restrictions on under-age gambling. Vulnerable populations such as the
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young (2005) or those with low socioeconomic status should be prioritized for prevention and
treatment since they are overly represented among compulsive gamblers (Volberg, 1996).
CONCLUSION
More data are needed for gambling treatment outcomes since this field of research is
relatively new (Potenza, 2006). Despite the challenges of limited data, important findings have
emerged. Cognitive behavioral treatment studies have more generalizable outcomes, long term
effects, and are frequently supported among gambling treatment researchers (Korn & Shaeffer,
2004; Ladouceur, 1994; Mason, 2005; Petry et.al, 2006; Sampl, 2006; Sharpe, 2002; Sylvain,
Ladouceur, and Boisvert, 1997; Toneatto & Ladouceur, 1990; and Toneatto & Ladouceur, 2003).
In practice, many publicly funded gambling programs use a multimodal approach to more fully
address the comprehensive needs of the presenting client (Korn & Shaeffer, 2004; Stinchfield &
Winters, 1999; 2001). The predominant therapy in multimodal should include cognitive behavioral
based on the strengths discuss in literature (Korn & Shaeffer, 2004; Ladouceur, 1994; Mason, 2005;
Petry et.al, 2006; Sampl, 2006; Sharpe, 2002; Sylvain, Ladouceur, and Boisvert, 1997; Toneatto &
Ladouceur, 1990; and Toneatto & Ladouceur, 2003). More data should be generated before
applying minimal therapeutic approaches for pathological gambling clients. However, minimal
interventions may provide suitable alternatives to individuals who may only experience problem
gambling and could reduce the likelihood of becoming an pathological gambler. Pharmacological
interventions should also be considered if the client is dually diagnosed with other psychological
disorders (Dannon, Lowengrub, Gonopolski, Musin & Kotler, 2005; Grant & Grosz, 2004). GA
and group therapies are widely used and should be available for use for those individuals who may
not be comfortable with the traditional clinical setting.
There are many similar characteristics among gamblers but each individual has unique needs
that must be assessed before prescribing a treatment. It is our hope that these collected data provide
Pathological Gambling Treatment Literature Review-Second Edition
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policy makers and practitioners with a variety of options to reduce the incidence of pathological
gambling within the state of Georgia.
Pathological Gambling Treatment Literature Review-Second Edition
Georgia State University-47
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Appendix: Pathological Gambling Assessment Instruments
Used in 2001-2007 Studies
Yale Brown Obsessive Compulsive Scale modified for pathological gambling
Structured Clinical Interview for the DSM IV-Axis I and II Modules
Obsessive Compulsive Drinking Scale Modified for Pathological Gambling
Gambling Symptom Assessment Scale
Criteria for Control of Pathological Gambling Questionnaire (CCPGQ)
Visual Analogue Scales assessing gambling frequency, severity, amount, and improvement
Sheehan Disability Scale
Herbert Louis Gambling Index
Ludo-Cage Test
Modified Obsessive Compulsive Drinking Scale
Gambling Severity Index
Addiction Severity Index
Modified Timeline Followback
Inventory of Drinking Situations Questionnaire
Iowa Gambling Task
Canadian Problem Gambling Index
Gambling Attitudes Scale
Gambling Attitudes and Belief Scale
Gambler’s Belief Questionnaire
Gambler’s Self-Efficacy Questionnaire
Gambler Metacognition Questionnaire
Massachusetts Gambling Screen
Psychopathological Indicators Associated with Gambling
Inadaptation Scale
State Trait Anxiety Inventory
Beck Depression Inventory
Hamilton Rating Scale for Anxiety
Hamilton Depression Rating Scale
Clinical Global Improvement-Impressions Scale
Profile of Mood States
Brief Symptom Inventory
Service Utilization Form
Beck Anxiety Inventory
Readiness to Change Questionnaire
Informational Biases Scale
Composite International Diagnostic Interview
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